Study reference

Study characteristics

Patient characteristics ²

Intervention (I)

Comparison / control (C) ³

Follow-up

Outcome measures and effect size ⁴

Comments

Ren, 2019

Type of study: retrospective cohort study

Setting and country: Beijing United Family Hospital and Tianjin Hospital, China

Funding and conflicts of interest:The authors declared that there are no conflicts of interest. No funding received.

Inclusion criteria: no fractures in initial radio graphs; the radiographic

Images showed that the first and second metatarsal had no diastasis

(less than 2 mm in gap), but only weight bearing view showed the

diastasis more than 3 mm; further images from CT showed some abnormality including ‘fleck sign’ or MRI showed plantar and interosseous branches of Lisfranc ligament rupture. ‘Fleck sign’ is a ‘small chip of bone found in the space between the first and second

metatarsal bases, which indicates avulsion of

the Lisfranc

ligament.

Exclusion criteria: not applicable

N total at baseline: 61 patients with subtle ligamentous Lisfranc injuries

Operative: n=20 (32.8%)

Conservative: n=41 (67.2%)

Important prognostic factors²:

Mean age total study group: 39 (range, 19-64) years

Sex:

Total study group: 62.2% Male

Groups comparable at baseline? Unclear.

Describe intervention (treatment/procedure/test):

Operative For the surgical treatment, a reduction clamp was used to hold the position of the first and second metatarsal, one or two position screw/screws (depending on whether there is a diastasis between first and

second cuneiform) were inserted. A posterior plaster splint was used

for two weeks after the wound was well healed, followed by a walking boot with a foot arch supporter for the followed four weeks.

Describe control (treatment/procedure/test):

Conservative For the conservative management of the undisplaced subtle

ligamentous Lisfranc injury, a posterior plaster splint was used for initial three to five days, followed by a full cast to fix the ankle in 90 

with foot arch remolding without weight bearing for totally six weeks. After the cast was removed, a walking boot with foot arch

supporter was used to allow patient to fully weight bear for another six weeks.

Length of follow-up: 12.3 months

Loss-to-follow-up:

Not applicable

Outcome measures and effect size (include 95%CI and p-value if available):

AOFAS, mean (SD)

Operative: 90.0 (3.7)

Conservative: 76.3 (13.0)

P-value: <0.05

Interpretation: higher scores is better outcome

Infection, n (%)

Operative: 1 (5.0)

Conservative: 0 (0)

P-value: not reported

Arthrosis, n (%)

Operative: 4 (11.8)

Conservative: 3 (37.5)

P-value: not reported

Authors’ conclusions

Although surgical

intervention for treating ligamentous injuries to Lisfranc joint is still controversial, we can learn a lesson and inform patients to give an appropriate warning to consider conservative and surgical management for undisplaced subtle Ligamentous Lisfranc injuries.

Remarks

Unclear whether groups are comparable in terms of age and sex

Garriguez-Pérez, 2021

Type of study: retrospective cohort study

Setting and country: hospital, country not reported

Funding and conflicts of interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this

article. ICMJE forms for all authors are available online. The author(s) received no financial support for the research,

authorship, and/or publication of this article.

Inclusion criteria: (a) traumatic widening of the first

intermetatarsal or intercuneal space, (b) complete clinical and radiographic history, and (c) minimum 1-year follow-up.

Exclusion criteria:(a) complete dislocation or fracture-

dislocation of the tarsometatarsal joint, (b) displaced

fracture of the base of the metatarsals, (c) open or crush

injuries, (d) associated injuries in the ipsilateral limb, and (e) associated comorbidities that made operative risk too high to propose operative treatment.

N total at baseline: 42 patients with subtle Lisfranc injuries

Operative: n=34 (81.0%)

Conservative: n=8 (19.0%)

Important prognostic factors²:

Mean age total study group: 49 (SD 17.5) years

Sex:

Total study group: 35.7% Male

Groups comparable at baseline? Unclear. Characteristics such as age, sex and BMI only provided for the whole study population. 

Describe intervention (treatment/procedure/test):

Operative for injuries displaced between 2 and 5 mm (stage II and III). A limited approach over the C1-M2 space was used to remove fat and scar tissue that might prevent proper reduction. The space was reduced using a clamp, and K-wires, screws, or dorsal plating were used for definitive fixation of

at least 2 of the 3 possible elements (C1-M2, M1-M2, or

C1-C2), according to surgeon’s preference (Figure 3). After operative treatment, an ankle splint was used for 1 week to allow healing of soft tissues. When the splint was removed, active ankle range of motion was promoted but weight bearing was not allowed for 6 weeks. Hardware removal was not done routinely, performing it only if discomfort was referred by the patient or if the follow-up radiographs showed signs of osteolysis.

Describe control (treatment/procedure/test):

Conservative for injuries displaced less than 2 mm (stage I). Use of posterior ankle splint for the first week until initial swelling has subsided and then replaced for a full ankle cast, which was kept for 6-8 weeks. Nonweight bearing

was indicated until the 12th week after the beginning of

treatment.

Length of follow-up: 4.3 (range, 1-8) years

Loss-to-follow-up:

Not applicable

Outcome measures and effect size (include 95%CI and p-value if available):

AOFAS, mean (SD)

Operative: 86.8 (6.6)

Conservative: 90.1 (13.7)

P-value: not reported

Interpretation: higher scores is better outcome

Arthrosis, n (%)

Operative: 4 (11.8)

Conservative: 3 (37.5)

P-value: not reported

Authors’ conclusions

Foot function does not seem diminished after sustaining injuries

Remarks

Groups are not comparable in types of complications

Relatively small sample size

Retrospective study and including different treatment modalities with different injury stages

No adjustment for confounding in statistical analyses

Graef, 2021

Type of study: retrospective cohort study

Setting and country: level I trauma centre, Germany

Funding and conflicts of interest: Open Access funding enabled and organized by Projekt

DEAL. Authors declare no competing interests.

Inclusion criteria: All patients who were treated due to an injury of the Lisfranc

joint in a single German level I trauma centre from

January 2011 until December 2020 were included in this

Study

Exclusion criteria: not reported

N total at baseline: 99 patients with Lisfranc injuries

Operative: n=79 (79.8%)

Conservative: n=20 (20.2%)

Important prognostic factors²:

Mean age operative: 45.47 [IQR, 15.84] years

Mean age conservative:

37.95 [IQR, 15.13)

Sex:

Operative: 50% male

Conservative: 59.5% male

Groups comparable at baseline? Baseline characteristics in terms of age, sex, trauma mechanisms etc not evenly distributed.

Describe intervention (treatment/procedure/test):

Operative not clear / no information

Describe control (treatment/procedure/test):

Conservative not clear / no information

Length of follow-up:

Operative: 4.50 (SD 2.42) years *using n=10 patients with FFI data

Conservative: 4.20 (SD 2.04) years *using n=10 patients with FFI data

Loss-to-follow-up:

Not applicable

Outcome measures and effect size (include 95%CI and p-value if available):

FFI, mean (SD)

Operative: 30.09 (28.59)

Conservative: 21.03 (28.46)

P-value: 0.487

Interpretation: higher scores is worse outcome

Authors’ conclusions the decision to treat Lisfranc injuries operatively or conservatively should always include qualitative parameters such as the grade of displacement (Buehren criteria A and C)

and quantitative variables like the M1-M2 distance (Buehren criterion B) but also take into account the trauma mechanism. If conservative treatment is chosen, regular checkups

are required to not miss secondary displacements.

Remarks

Propensity score matching applied to evenly match groups A and B. groups were matched for age, sex, fracture classification, injury mechanism, total number of collateral fractures of the foot and ankle joint, and follow-up time after treatment.

Bonferroni correction was applied to account for multiple testing

Possibility of selection bias due to design. Operative group consisted mainly of homolateral dislocations and partial or complete divergent dislocations. Conservative group particularly consisted of isolated partial displacement.

Study reference

Study characteristics

Patient characteristics ²

Intervention (I)

Comparison / control (C) ³

Follow-up

Outcome measures and effect size ⁴

Comments

Sun, 2022

Type of study: RCT

Setting and country: hospital, China

Funding and conflicts of interest: This

work was supported by the Natural Science Foundation of Beijing (No. 7212020), the Science and Technology Planning Project of Beijing Municipal Education commission (No. KM202110025013), and the Beijing Thousand Talents Project (No. 2020A43). The authors declare no competing interests

Inclusion criteria: (1) age more than sixteen (closed osteoepiphysis), (2) purely ligamentous

and fracture dislocation, and (3) with or without

other TMT joint injuries.

Exclusion criteria: (1) previous Lisfranc injuries or foot abnormalities, (2) pathological

fracture, (3) with neurovascular or head injury, and

(4) with cognitive impairment

N total at baseline: 88

Intervention: 44

Control: 44

Important prognostic factors²:

For example

age ± SD:

I: 41.9 ± 7.8

C: 39.4 ± 8.4

Sex:

I: 65.0% M

C: 63.2% M

Diabetes:

I: 8.0%

C: 10.0%

Smoker:

I: 20.0%

C: 16.0%

Groups comparable at baseline? More men than women in both groups. More smokers in the ORIF group, but both not statistically significant.

Describe intervention (treatment/procedure/test):

ORIF For open reduction and internal fixation, because dislocation

of the first TMT joints may potentially loss some

essential anatomical landmarks which influenced precise reduction and alignment, the second ray should be reduced first. Then, the first ray was reduced regarding the second ray as an anatomical template and fixed temporarily by K-wires. The other TMT joints were reduced finally. A large point reduction clamp was used to maintain the reduction between the second metatarsal base and the medial cuneiform. The homerun screw was inserted to fix the joint

using solid 2.7-mm cortical screws. The anatomic reduction and alignment of joints were confirmed visually and under fluoroscopy. Bridging plates (DePuy Synthes, Warsaw, IN, USA) between joints were used for the medial three rays. If the lateral column was unstable or dislocated, it was assessed under fluoroscopy after treatment of the medial three rays. When without satisfactory reduction, the lateral column was reduced and stabilized by temporary K-wires but not fused. The K-wires were removed at six weeks post-operatively. If the lateral column could not be closed reduced, then the

second incision along the fourth metatarsal was made for reduction and fixation.

Describe control (treatment/procedure/test):

PA The exact same approach and principles were used as that in performing open reduction and internal fixation. The first TMT joint was fused only, and

ORIF was completed for the second and third TMT joints.

And the joints were also fused by the same bridging plates. The only additional step was that the articular cartilage was removed from both the surfaces of the first TMT joint. The lateral column was also reduced and stabilized by temporary

K-wires but not fused. No additional bone graft was needed. The joint alignment and implant position were checked under fluoroscopy during surgery, and then, the wound was irrigated, closed, and dressed.

Length of follow-up: 37.8 (range, 24-48) months

Loss-to-follow-up:

Intervention: 0 (0%)

N (%)

Reasons (describe): not applicable 

Control: 1 / 44

N (%)

Reasons (describe): not reported

Incomplete outcome data:

Intervention: 4 (10%)

N (%)

Reasons (describe): not reported

Control: 5 (11.4%)

N (%)

Reasons (describe): not reported

Outcome measures and effect size (include 95%CI and p-value if available):

AOFAS, mean ± SD

Note, this outcome is measured at 12 months

ORIF: 77.4 ± 5.3

PA: 84.3 ± 7.3

P value: <0.01

Arthrosis, n (%)

ORIF: 8 (20)

PA: 0

P value: <0.05

Authors’ conclusions: PA of the first TMT joint provided a better medium-term outcome than ORIF for Lisfranc injuries with the first TMT dislocation. PA prevented redislocation, pain, and revision as well. Therefore, PA of the first TMT joint was indicated for Lisfranc injuries with the first TMT joint

dislocation.

Remarks

During follow-up visits, neither patients nor the surgeons were blinded.

Small sample size

Relatively high drop-out rate

Stødle, 2020

Type of study: RCT

Setting and country: Level 1 trauma center, country not reported

Funding and conflicts of interest: Are H. Stødle, MD, reports grants from Sofies Mindes Ortopedi AS, Oslo, Norway, during the conduct of the study. The authors disclosed receipt of financial support from Sophies Minde Ortopedi.

Inclusion criteria:

Lisfranc injuries with instability

of the medial 3 TMT joints and no fractures in relation to

the first TMT joint, in patients between 18 and 65 years old.

Minor capsular avulsions in relation to the first TMT joint

was accepted as a primarily ligamentous injury.

Exclusion criteria: concomitant other major

lower extremity injuries / polytrauma, open injuries, previous foot pathology, diabetes mellitus, neuropathy, and

peripheral vascular disease.

N total at baseline: 48

ORIF: 24

PA: 24

Important prognostic factors²:

For example

age ± SD:

I: 34 (IQR 28-40)

C: 30 (IQR 23-40)

Sex:

I: 45.8% M

C: 45.8% M

Groups comparable at baseline? Mostly yes, but a higher rate of ligamentous injuries in the PA group was observed

Describe intervention (treatment/procedure/test):

ORIF A 2-incision technique was used, with one longitudinal dorsomedial incision over

the first TMT joint and a second incision over the third TMT joint. A skin bridge of at least 4 cm between the incisions

was preserved to reduce the risk of wound complications. The 3 medial TMT joints were exposed.

In the patients randomized to dorsal bridge plating, the cartilage of the first TMT joint was left intact.

In the BP group, the first TMT joint was bridged with 2.7-mm locking plate.

Describe control (treatment/procedure/test):

PA As all of the patients were treated with a primary arthrodesis of the second

and third TMT joint, the cartilage was removed from

these joints and the subchondral bone was multiperforated using a 2-mm drill bit to enhance fusion. No bone graft was used.

In the PA group, the arthrodesis of the first TMT joint was fixed with two 2.7- or 3.5-mm fully threaded screws with interfragmentary compression.

The primary arthrodesis of the second and third TMT joints was either fixed using 2.7- or 3.5-mm fully threaded screws or, in case of a severely comminuted

joint, a locking plate was used.

A “homerun-screw”

was then placed from the medial cuneiform to the base of the second metatarsal securing the Lisfranc mortise. After

reduction and fixation of the 3 medial TMT joints, the

reduction of the fourth and fifth TMT joints was assessed. If displaced, the 2 lateral TMT joints were reduced and stabilized

using 1.6-mm Kirschner wires.

Length of follow-up: 24 months

Loss-to-follow-up:

Intervention: not reported

N (%)

Reasons (describe): not reported 

Control: not reported

N (%)

Reasons (describe): not reported

Incomplete outcome data:

Intervention: not reported

N (%)

Reasons (describe): not reported

Control: not reported

N (%)

Reasons (describe): not reported

Outcome measures and effect size (include 95%CI and p-value if available):

AOFAS, mean ± SD

12 months follow-up

ORIF: 79 ± 16

PA: 85 ± 10

P-value: 0.12

24 months follow-up

ORIF: 85 ± 15

PA: 89 ± 9

P-value: 0.32

Nonunion, n (%)

ORIF: 2 (8.70)

PA: 1 (4.55)

P-value: >0.99

Arthrosis, n (%)

ORIF: 11 (45.8)

PA: 0 (0)

P-value: not reported

Hardware removal, n (%)

ORIF: 5 (20.8)

PA: 7 (30.4)

P-value: 0.45

Infection

“One patient had a superficial wound infection in the BP group”(only in the text)

Information not provided for PA group.

Authors’ conclusions Both the temporary bridge plate (BP) group and the primary arthrodesis (PA) group yielded good outcome scores when treating Lisfranc injuries. We did not find superiority of the BP group compared to the PA group according to the AOFAS midfoot score. The first metatarsal was better aligned in the

BP group. Despite avoiding transarticular screw damage by bridge plating the first TMT joints, there was a high rate of radiologically detected osteoarthritis in the first TMT joint. The long-term effects of post-traumatic osteoarthritis is still unknown and longer follow-up is required.

Remarks

Lack of external validity, since only ‘low-energy’ injuries were included, which are known to have better results than high-energy injuries.

Possibility to have missed patients with minor symptoms for nonunion, because only patients with clinically suspected nonunion were evaluated.

Patients and examiner were not blinded for the treatment.

Henning, 2009

Type of study: RCT

Setting and country: not reported

Funding and conflicts of interest: not reported

Inclusion criteria:

Acute Lisfranc injury of less than 3 months duration and closed physes/skeletal maturity.

Exclusion criteria

Major intra-articular fracture pattern, prior foot trauma, prior foot

infection, prior foot surgery, prior foot pathology, chronic injury of greater than three months duration, or associated medical comorbidities such as diabetes mellitus, peripheral

vascular disease, peripheral neuropathy, or autoimmune

disease.

N total at baseline: 32

ORIF: 14

PA: 18

Important prognostic factors²:

For example

age ± SD:

ORIF: 37 (range, 20-58) years

PA: 40 (range, 25-73) years

Sex:

ORIF: 64.3% M

PA: 66.7% M

Groups comparable at baseline? Yes, sex, age, mechanism of injury, and smoking rate was similar between groups (p >0.05)

Describe intervention (treatment/procedure/test):

ORIF primary ORIF consisted of a 9- to 10-cm, dorsal longitudinal

incision over the interval at the base of the first and second TMT joints. This approach allowed visualization and reduction of the first, second, and medial half of

the third TMT joints. The first TMT was reduced with a tenaculum clamp and flexion force avoided plantar gapping or malreduction. Crossed 0.062 Kirschner wires secured the reduction. With a tenaculum clamp compressing the joint, a retrograde 0.062 Kirschner wire secured the joint. The

medial aspect of the third TMT was visualized through the

same incision. When necessary, the lateral 8 cm longitudinal, universal incision over the fourth metatarsal allowed access

to the lateral aspect of the third and entire visualization

of the fourth and fifth TMT joints. After the third TMT

was reduced with a tenaculum clamp, a 0.062 Kirschner

wire was percutaneously inserted retrograde to stabilize the third TMT joint. If the Kirschner wires were inserted close to the TMT, the wire would not interfere with retrograde drilling and screw insertion. The fourth and fifth TMTs were reduced with dental picks and tenaculum clamps.

Retrograde percutaneous 0.062 Kirschner wires were inserted

perpendicular to the TMT joint and into the subchondral bone of the cuboid. Temporary reduction was confirmed with anterior-posterior (AP), lateral (Lat), and oblique (Obl) intraoperative fluoroscopic views. Final stabilization was performed in a medial to lateral direction. A step was created on the mid anterior first MT cortical surface with a perpendicular drill through the first cortex only. A 2.5-mm drill with drill sleeve was used to cross the joint about 30 degrees from the anterior cortical surface.17 Periarticular screws (Zimmer, Warsaw, IN) with a 3.5-mm shaft and a 2.7-mm head size increased joint stability and screw longevity

with lessened cortical splitting. Two crossed 3.5-mm cortical

screws were inserted at the first TMT joint. The retrograde screw was inserted along the medial half of the first TMT perpendicular to the joint. The antegrade screw was inserted from the lateral half of the medial cuneiform into the base of the first MT. A single retrograde 3.5-mm periarticular

screw was inserted perpendicularly across the second TMT joint on the AP view. A percutaneous incision over the mid portion of the third metatarsal was used for insertion of a single retrograde 2.7-mm or 3.5-mm periarticular cortical screw across the third TMT joint. All screws were inserted in a neutral, not lag technique. The final screw position and TMT reductions were confirmed with fluoroscopy. The fourth and fifth TMT Kirschner wires were cut below the skin. A

posterior splint in neutral position was applied. When present, an associated cuboid fracture was reduced and stabilized via the lateral longitudinal incision. A 2.5-mm external fixator (Synthes, Paoli, PA) was inserted across the

cuboid from the calcaneus to the fifth MT shaft. The impacted

articular surface was carefully elevated with an osteotome

or elevator followed by insertion of allograft bone in the void. A mini “T” plate (Synthes, Paoli, PA) stabilized the cuboid fracture and allowed for insertion of “raft” screws into the subchondral bone. Because anatomical fixation of the cuboid articular surface determined TMT reduction and

restoration of the lateral column length, the cuboid fracture

fixation was performed before fourth and fifth TMT reduction

and stabilization with Kirschner wires.

Describe control (treatment/procedure/test):

PA For PA, the same dorsal access was provided with the two longitudinal incisions. Since the first, second, and third TMT

joints are “non-essential” or relatively immobile, the TMT joints were fused. Since the fourth and fifth TMT “essential” or more mobile, the fourth and fifth TMT joints were not fused. The reduction and fixation sequence was similar to PORIF, i.e. medial to lateral. The articular surface was removed with one-quarter inch osteotomes and small

curettes. Final subchondral preparation required 2.0 mm drill perforation through the subchondral bone into cancellous

bone. The temporary stabilization of the joints was similar to the PORIF group. Screws were inserted via a lag technique to compress the subchondral surfaces with the same screw configuration as PORIF. No additional bone graft or allograft was necessary.

Length of follow-up: 24 months

Loss-to-follow-up:

3 patients dropped out postoperatively and 5 patients were lost to follow-up early in the study. At the time of the final phone survey, an additional 9 patients were unable to be contacted after an exhaustive search.

Note: drop out rate and reasons were not reported per treatment group.

Incomplete outcome data:

ORIF: not reported

N (%)

Reasons (describe): not reported

PA: not reported

N (%)

Reasons (describe):

not reported

Outcome measures and effect size (include 95%CI and p-value if available):

Hardware removal, n (%)

ORIF: 11 (79)

PA: 3 (17)

P-value: <0.05

Infection, n (%)

ORIF: 0 (0)

PA: 1/18 (5.56) à superficial cellulitis

P-value: not reported

Neural injury

No neural injury was noted in both ORIF and PA group (only in text)

Nonunion

“one delayed union associated with a broken first TMT joint screw healed at the 6-month mark, and one nonunion of a first TMT joint was treated nonoperatively” in the PA group” (only in the text). This information was not provided for the ORIF group.

Authors conclusion: PA resulted in a statistically significant decrease in the

number of follow-up surgeries performed compared to ORIF

if hardware removal is routinely performed.

Remarks

Small sample size

High drop out rate during follow-up

Non-blinding of the surgeon who directed examinations and grading of radiographs may have resulted in bias

The study was discontinued prematurely, because patients undergoing PA were doing clinically as well as the ORIF patients with significantly fewer follow-up surgical procedures and without adverse outcomes.

Ly, 2006

Type of study: RCT

Setting and country: not reported

Funding and conflicts of interest: The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to

provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or

associated.

Inclusion criteria: the Lisfranc injury had to be primarily ligamentous, with no major fractures present. Lisfranc injuries with a fleck sign were considered to be primarily ligamentous.

Exclusion criteria: commuted intra-articular fracture at the base of the first or second metatarsal; any other substantial foot, ankle, or leg injury; a previous attempt at surgical management of the same injury; insulin-dependent diabetes mellitus; ipsilateral ankle fusion; peripheral vascular disease; peripheral neuropathy; and rheumatoid arthritis.

N total at baseline: 41

Intervention: 20

Control: 21

Important prognostic factors²:

For example

age ± SD:

I: 32.4 (range, 19-52) years

C: 32 (range, 19-42) years

Sex:

I: 65% M

C: 66.7% M

Groups comparable at baseline? Yes

Describe intervention

(treatment/procedure/test):

ORIF Two dorsal longitudinal incisions—one between the first and second metatarsals and the second centered between the fourth and fifth metatarsals—were made. Open reduction and screw

fixation of the first, second, and third metatarsal-cuneiform

joints was performed. Then, if necessary, Kirschner

wires were placed in each of the lateral two rays, but the rays

were not fused. Seven patients in the open-reduction group required Kirschner-wire fixation of the lateral rays. The Kirschner wires were removed between six and eight weeks postoperatively.

The screws were not routinely removed unless they caused symptoms, and they were never removed before three months.

Describe control

(treatment/procedure/test):

PA Standard incisions were made as described for the open-reduction group. Open reduction was performed, cartilage and

fibrous tissue were resected, and the joints were decorticated.

Reduction and screw fixation was then performed. If the third

metatarsal-cuneiform joint was seen to be displaced on the computed tomography scan or was clearly unstable on direct examination, it was fused in the same fashion. The rationale

for treatment of the lateral two rays was exactly the same as the rationale in the open-reduction group. Nine patients in the arthrodesis group underwent temporary Kirschner-wire fixation of the lateral two rays.

Length of follow-up: 42.5 months

Loss-to-follow-up:

ORIF: not reported

N (%)

Reasons (describe): not reported

PA: not reported

N (%)

Reasons (describe): not reported

Incomplete outcome data:

ORIF: not reported

N (%)

Reasons (describe): not reported

PA: not reported

N (%)

Reasons (describe): not reported

Outcome measures and effect size (include 95%CI and p-value if available):

AOFAS, mean (range)

Measured at 24 months follow-up

ORIF: 68.6 (16-100)

PA: 88.0 (63-100)

P-value: 0.005

Measured at final follow-up

ORIF: 57.1 (16-100)

PA: 86.9 (63-100)

P-value: 0.0001

Hardware removal, n (%)

ORIF: 16 (80)

PA: 4 (19)

P-value: not reported

Nonunion, delayed union

“One patient had a delayed union” and “one patient with a nonunion […]” in the PA group (only in the text). No such information was provided for the ORIF group.  

Authors conclusion: Because of the poor healing potential of

the ligament-osseous interface and the trend toward a higher rate of correction loss, increasing deformity, and degenerative arthritic changes, we believe that primarily ligamentous injuries are a subset of Lisfranc joint injuries that are not as amenable to internal fixation. We believe that stable arthrodesis is a better primary treatment for these injuries, with superior short and medium-term outcomes than those following open

reduction and internal fixation.

Remarks

The allocation of

treatment with an open-randomization, odd-or-even format could have introduced selection bias. Using a random-numbers

table or computerized randomization would have been a better way to allocate our patients.

The attending surgeon performed the follow-up clinical examination and gathered the questionnaires, which raises concern about bias.

Hardware removal could have contributed to the poor results observed in the ORIF group.

Author, year

Selection of participants

Was selection of exposed and non-exposed cohorts drawn from the same population?

Exposure

Can we be confident in the assessment of exposure?

Outcome of interest

Can we be confident that the outcome of interest was not present at start of study?

Confounding-assessment

Can we be confident in the assessment of confounding factors? 

Confounding-analysis

Did the study match exposed and unexposed for all variables that are associated with the outcome of interest or did the statistical analysis adjust for these confounding variables?

Assessment of outcome

Can we be confident in the assessment of outcome?

Follow up

Was the follow up of cohorts adequate? In particular, was outcome data complete or imputed?

Co-interventions

Were co-interventions similar between groups?

Overall Risk of bias

Definitely yes, probably yes, probably no, definitely no

Definitely yes, probably yes, probably no, definitely no

Definitely yes, probably yes, probably no, definitely no

Definitely yes, probably yes, probably no, definitely no

Definitely yes, probably yes, probably no, definitely no

Definitely yes, probably yes, probably no, definitely no

Definitely yes, probably yes, probably no, definitely no

Definitely yes, probably yes, probably no, definitely no

Low, Some concerns, High

Ren, 2019

Definitely yes

Reason: all patients had undisplaced subtle ligamentous Lisfranc injury

Definitely yes

Reason: surgeons performed the procedures (i.e. exposures)

Definitely yes

Reason: all outcomes were assessed after treatment

Definitely no

Reason: confounding factors are not assessed.

Definitely no

Reason: no adjustment for confounding in statistical analyses, because confounders were not defined a priori.

Probably yes

Reason: not clearly described, but no reason to believe that this was not well performed. 

Definitely yes

Reason: Outcome data were complete.

No information

Some concerns for all outcomes 

Reason: no adjustment for confounding

Garriguez-Pérez, 2021

Definitely no

Reason: different types of Lisfranc injuries (stage I, II and III) constituted the cohort and were differently treated.

Definitely yes

Reason: Stage I injuries received conservative treatment, stage II and III injuries received operative treatment. The treatments were well performed.

Definitely yes

Reason: all outcomes were assessed after treatment.

Definitely no

Reason: confounding factors are not assessed.

Definitely no

Reason: no adjustment for confounding in statistical analyses, because confounders were not defined a priori.

No information

No information

No information

Some concerns for all outcomes

Reason: patients not comparable, no adjustment for confounding

Graef, 2021

Definitely no

Reason: different types of Lisfranc fractures were differently treated.

Definitely yes

Reason: treatments were well performed.

Definitely yes

Reason: all outcomes were assessed after treatment.

Definitely yes 

Reason: the authors of the study thought a priori about potential confounders, such as age, sex, and trauma mechanism.

Definitely yes

Reason: propensity score matching was applied. 

Probably yes

Reason: the FFI-F is a valid scale to assess foot function

No information

No information

Some concerns for all outcomes (FFI)

Reason: concerns related to study population

Study reference

(first author, publication year)

Was the allocation sequence adequately generated?

Definitely yes

Probably yes

Probably no

Definitely no

Was the allocation adequately concealed?

Definitely yes

Probably yes

Probably no

Definitely no

Blinding: Was knowledge of the allocated

interventions adequately prevented?

Were patients blinded?

Were healthcare providers blinded?

Were data collectors blinded?

Were outcome assessors blinded?

Were data analysts blinded?

Definitely yes

Probably yes

Probably no

Definitely no

Was loss to follow-up (missing outcome data) infrequent?

Definitely yes

Probably yes

Probably no

Definitely no

Are reports of the study free of selective outcome reporting?

Definitely yes

Probably yes

Probably no

Definitely no

Was the study apparently free of other problems that could put it at a risk of bias?

Definitely yes

Probably yes

Probably no

Definitely no

Overall risk of bias

If applicable/necessary, per outcome measure

LOW

Some concerns

HIGH

Sun, 2022

Definitely yes

Reason: a random number generated system was used for the blinded process.

Probably yes

Reason: numbered envelopes were used.

Definitely no

Reason:

Patients and healthcare providers were not blinded

Data analysts were blinded.

Probably yes

Reason: it was stated that 1 patient was lost to follow-up and 9 patients had missing data. Missing data were not imputed

Probably yes

Reason: the protocol is not on clinical trials.gov. However, all outcomes that have been described are presented in tables

Definitely yes

Reason: authors have no conflicts of interest. No reason to believe that the funders of this project influenced study outcomes.

Some concerns for all outcomes.

Reason: lack of blinding and potential problem with loss to follow-up.

Stødle, 2020

Definitely yes

Reason: A random allocation rule was used.

Definitely yes

Reason: Allocations were kept in sealed, opaque envelopes and were manually shuffled.

Definitely no

Reason: healthcare provider and patients were not blinded.

Definitely no

Reason: there was no loss to follow-up

Probably yes

Reason: more outcomes reported in article than in protocol

Definitely no

Reason: potential of selection bias due to inclusion of only low-energy injuries that are known to have better results than high-energy injuries. And main reports a grant from Sofies Mindes Ortopedi, but no reason to believe that this institution influenced study results.

Some concerns for all outcomes

Reason: lack of blinding and problem with selection bias

Henning, 2009

Definitely yes

Reason: A random number generating system was used.

Probably yes

Reason: envelopes were used, but not clear whether envelopes were sealed and opaque.

Definitely no

Reason: healthcare providers were not blinded. Not clear whether patients were blinded.

Probably yes

Reason: three patients dropped out postoperatively and five patients were lost to follow-up early in the study. At the time of the final phone survey, an additional nine patients were unable to be contacted.

Probably yes

Reason: all outcomes that have been described in the article are presented in tables

Definitely no

Reason: three different surgeons performed the procedures and the trial was discontinued prematurely

Some concerns

Reason: lack of blinding and trial was discontinued prematurely.

Ly, 2006

Definitely no

Reason: An odd-or-even process was used.

No information

Definitely no

Reason: healthcare providers were not blinded.

No information

Probably yes

Reason: all outcomes that have been described in methods are presented in tables or in text.

Definitely yes

Reason: the authors did not receive grants or outside funding in support of their research. They did not get payments from commercial entities

Some concerns for all outcomes

Reason: randomization process and lack of blinding.